COURT OF APPEAL, FIRST APPELLATE DISTRICT MEDIATOR APPLICATION (Attach your resume and any additional pages) Name ______________________________________________________________________________ Firm or Agency Street or P.O. Box City or Town Phone County Fax Zip Code E-mail 1. Describe your education, including degrees and the dates received. 2. Describe any mediation training you have received. For each training, give the trainer’s name, the dates attended, and the total hours. 3. Describe the subject matter of five disputes for which you have been a mediator in the past five years, with the dates. Do not give the names of the parties. State whether you were a sole mediator or a co-mediator. A. B. C. D. E. 4. List other court mediation panels of which you are a member. 5. State the name of any organization for which you have provided mediation services during the past five years. American LegalNet, Inc. www.FormsWorkFlow.com 6. Check your areas of substantive expertise: ( ) Attorney’s Fees ( ) Family Law ( ) Partnership ( ) Business /Contract ( ) Health Care ( ) Personal Injury ( ) Construction ( ) Housing ( ) Probate ( ) Defamation ( ) Insurance ( ) Professional Negligence ( ) Eminent Domain ( ) Intellectual Property ( ) Public Entity ( ) Employment/Labor ( ) Landlord/Tenant ( ) Real Estate ( ) Environment ( ) Medical Malpractice ( ) Securities Other (specify): ________________________________________________________________ 7. If you are an attorney, what is your State Bar No.? _____________________ 8. How many years have you been in active practice? ________ If none, please explain. 9. What is or was the nature of your practice? 10. Are you certified in any specialty? If so, please list. 11. What percentage of your practice has been representing plaintiffs ____ defendants ____? 12. How many of the following have you completed in the past five years?: Jury trials _____ Court trials _____ Arbitrations _____ Appeals _____ 13. Describe your appellate experience. 14. Is your mediation style facilitative or evaluative/directive? 15. List any languages, other than English, in which you can conduct a mediation. 16. Describe your normal fee schedule, including any sliding-scale or pro-bono provisions. 17. State any other information that should be considered in respect to your application. American LegalNet, Inc. www.FormsWorkFlow.com 18. List the names and telephone numbers of three persons familiar with your mediation or appellate skills, indicating which applies. Name Phone ( ) Mediation ( ) Appellate Name Phone ( ) Mediation ( ) Appellate Name Phone ( ) Mediation ( ) Appellate Please read and sign the following agreement: A. In consideration of the free appellate mediation training to be provided by the Court, I agree to accept up to four mediation referrals. B. I agree to be bound by the Court’s mediation rules and procedures. C. I agree to waive any and all claims against the Court in connection with my mediation of any Court-referred dispute. D. I agree to adhere to the ethical standards for mediators adopted by the Court. E. (For attorneys) I am in good standing with the State Bar of California. Date: ________________ Name (print:) ______________________________________ Signature: _________________________________________ MAIL THIS APPLICATION YOUR RESUME, AND ANY OTHER ATTACHMENTS TO: GARY WEINER, MEDIATION PROGRAM ADMINISTRATOR COURT OF APPEAL, FIRST APPELLATE DISTRICT 350 McALLISTER STREET SAN FRANCISCO, CA 94102 OR FAX TO 415-865-7374 09/13/2011 American LegalNet, Inc. www.FormsWorkFlow.com